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What's in a name

18 November 2019

Dr W and her dental nurse Ms S were a formidable team. They had worked together for ten years in a reputable practice renowned for its patient-centric approach to care.

On one particularly busy day, Ms S seemed a little distant. Her lacklustre demeanour reflected her concern for a family member who had been taken ill the day before. By the time the fifth patient of the day was due they were running late and Ms S was setting up the surgery in preparation for the next patient who was attending for completion of endodontic treatment that had been started at a previous appointment.

Dr W reviewed her notes ­­­­­­­­­­­­­– written at the time of the first visit – and asked her nurse to call the patient, Mr F, from the waiting room.

When Mr F walked into the surgery, Dr W remarked that he was not wearing a suit and tie that day. She recalled that Mr F had been formally dressed on each of the previous visits, but today he was casually dressed. Dr W had noticed that Mr F appeared a little perplexed by her remarks but thought nothing of it.

Dr W advised Mr F that she hoped she would be able to complete his endodontic therapy and indicated that this would take approximately 45 minutes. Mr F was taken aback by this and Dr W assumed that his reaction was probably related to her comment about the duration of the appointment.

Dr W applied some topical anaesthetic to the injection site with a cotton wool roll and it was only when she examined the tooth, she noticed it was unrestored. This set alarm bells ringing and she realised that the wrong patient was sitting in the chair.

Dr W apologised to Mr F and explained that another patient with the same name had recently undergone the first part of root canal therapy and this had caused the confusion. Mr F was not prepared to accept the apology and said he wished to make a formal complaint.

Dr W contacted one of the dentolegal consultants at Dental Protection who assisted her with a written response. It was explained to Mr F that it was a coincidence that both Mr Fs had been booked in on the same day at similar times and were due to see different dentists. When the nurse had called for Mr F in the waiting room, the ‘wrong’ Mr F had stood up and the nurse, normally quite vigilant, had not noticed given her preoccupation with a family member’s illness.

The written response was accepted as a reasonable explanation and he was content to let the matter drop. He indicated that he had lingering concerns about what had happened and had interpreted the event as a risk that he might have received someone else’s treatment and on this basis said that he would not be returning to the practice.

Learning points

  • When patients are known to the dentist, this type of error is unlikely to arise. It is more likely when the patient is new or has only seen the dentist a few times and the visual image of the patient has not yet been committed to memory.
  • There should be other means of confirming identities in situations where the patient is not known to the dentist.
  • Patients in the waiting room may be hard of hearing and may mishear the name that is called.
  • Checking and confirming the identity at the outset can save embarrassment later.
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These case studies are based on real events and provided here as guidance. They do not constitute legal advice but are published to help members better understand how they might deal with certain situations. This is just one of the many benefits dental members enjoy as part of their subscription. 
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